Derbyshire Healthcare NHS Foundation Trust

4. Mrs A complains about the care and treatment her son, Mr B, received from the Trust, prior to his death on 14 May 2023. She complains the Trust:

• failed to recognise her son had a diagnosis of autism or that he was a vulnerable adult with a history of depression and self-harm • did not take his diagnosis and disability into account when providing care and treatment following an attempted suicide in January 2023 • failed to provide follow up care to Mr B following attempted suicides in January and April 2023 • failed to notify his family of the attempt on his own life in January and April 2023.

5. Mrs A says her son’s death was avoidable. She says if the Trust identified he was a vulnerable adult, with a history of depression and self-harm, he would have been given access to the correct support, and he may not have taken his own life.

6. She told us the Trust’s failings led to Mr B’s death, which has left both her and her family distraught and their lives have been ripped apart. She told us they will never get over the death of Mr B.

7. Mrs A is seeking service improvements and a financial remedy.

9. The Health Service Commissioners Act 1993 (section 4) says we cannot investigate a complaint if there is a legal route the complainant could pursue, unless we consider it is not reasonable for them to do so. This ensures the Ombudsman does not interfere with matters which are in the remit of the courts.

10. Mrs A says the Trust was ‘negligent’ in the care and treatment it provided to her son between January and May 2023. She feels this negligence contributed to his death.

11. Mrs A is seeking financial remedy to compensate for the severe emotional impact she has experienced. Mrs A was unable to arrive at a specific figure as she explained she cannot put a price on her son’s life.

12. Although we do not have a figure for financial remedy, due to the serious nature of Mrs A’s complaint and the severe impact it has had on her and her family, it is likely the sum which is sought is to be a significant amount.

13. There is an available legal route which Mrs A could use to potentially achieve the financial compensation she is seeking. She could pursue a clinical negligence claim against the Trust as she is claiming the care and treatment provided fell below the expected standard and that this led to an avoidable death.

14. Mrs A would also like the Trust to make service improvements as a result of what happened. Whilst legal action cannot directly achieve service improvements, this is likely to be a byproduct of successful legal action.

15. We asked Mrs A if there any barriers which would make it difficult for her to pursue legal action. Mrs A told us she had considered seeking legal advice on her case and she was happy and willing to explore this further.

16. In summary, we assess there is a legal route which Mrs A could pursue to achieve her desired financial outcome, and this is something the courts are best placed to achieve. Miss A may also achieve service improvements as a result of successful legal action.

17. As we have not seen any clear barriers to legal action, we consider it is reasonable for Mrs A to pursue legal remedy. She can return to our service if she is unable to get legal representation, or if following legal action, she has outstanding outcomes we can achieve.

18. If Mrs A chooses to bring the complaint back to us, we would advise she does so as promptly as possible. This is because we have a one-year time-limit by which to consider complaints (from the day a person became aware of their reason to complain.). We have discretion to set this time-limit to one side if there are strong reasons to do so.

19. It is clear it has been a very difficult period for Mrs A and her family, and the loss of Mr B continues to affect them greatly.

1. We have carefully considered Mrs A’s complaint about the Trust.

2. We recognise the immense distress Mrs A experienced and how difficult it must be for her to discuss the loss of her son.

3. We consider Mrs A could take legal action on the matter she has brought to us. As such, we have decided to take no further action at this stage.